Cost-effectiveness of Obesity Prevention Strategies: Steve Gortmaker, Ph.D. Harvard School of Public Health Childhood O

1. Cost-effectiveness of Obesity Prevention Strategies: Steve Gortmaker, Ph.D. Harvard School of Public Health Childhood Obesity Prevention Coalition Dec 3, 2013 Supported by grants from CDC (1U48DP001946), including the Nutrition and Obesity Policy, Research and Evaluation Network, the Robert Wood Johnson Foundation, and the JPB Foundation. This work is solely the responsibility of the authors and does not represent official views of the Centers for Disease Control and Prevention or any of the other funders.

2. Outline for Today • What changes do we need to alter child obesity in the US? The energy gap • Lancet Series: causes, trends and best value for money policies and programs • CHOICES cost effectiveness modeling in US • SSB tax, School based physical activity, reducing marketing to children • Recent Boston Initiatives • Implications for Action

3. Cover of The Economist

4. the energy gap Claire Wang & Steve Gortmaker

5. Energy Gap Framework: Rationale • Excess weight gain during growth is a result of energy intake exceeding expenditure. Measuring underlying drivers of population weight shift informs surveillance, goal setting and benchmarking progress. • Definition: Imbalance between calories children consume each day and calories required to support normal growth, physical activity, and body function. Reference: Wang YC, Gortmaker SL, Sobol AM, Kuntz KM. Pediatrics 2006. 118 (6): 1721-1733

6. Kcal in Kcal out Energy Balance (EB) Body Weight (Kg) Translating Excess Weight Gain toDaily Energy Gap • Assumptions • 3500 kcal accumulated= 1 lb weight gain as fat • Efficiency of energy storage from food: 50-75% • Linear accumulation of excess weight over 10 y • Adjustment for higher energy expenditure following weight gain

7. Average Daily Energy Gap (kcal/day): 1988-94 to1999-2002 • Behavioral implications of 150 kcal for an average kid: • Replacing 1 can of soda (12 oz) with water (140 kcal) • Reducing TV watching by an hour (100 kcal/day) • Walking ~1.9 hours instead of sitting • Increasing PE from 1 to 3 times/week (240 kcal)

8. The Energy Gap and Recent Obesity Trends • Increasing childhood obesity in US • What will it take to halt, or reverse these trends so we can reach the Healthy People goals? Wang, Orleans, Gortmaker. (2012) Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap. Am J Prev Med.

9. 64.

10. Recent work of Hall • The bodyweight response to a change of energy intake is slow, with half times of about 1 year • An adult with a BMI higher than 35 kg/m², (14% of US population), needs a change greater than 500 kcal per day to return to the average bodyweight of the 1970s • Children have much less excess weight! Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker SL, Swinburn BA. Quantification of the effect of energy imbalance on bodyweight. Lancet. 2011 Aug 27;378(9793):826-37.

11. Science, Policy and Action • Governments need to lead obesity prevention, but so far few have shown leadership • It is crazy that we do effectiveness studies and do not measure intervention costs • Empirical evidence of how to prevent obesity is limited but growing: cost-effectiveness policy and program analyses indicate several are both effective and cost saving Gortmaker, Swinburn, Levy et al. Changing the future of obesity: science, policy, and action, Lancet 2011; 378: 838–47.

12. Evidence for Leveling Off Childhood Overweight/Obesity Rates • Happening all over US • In MA 2009-2012 75% of school districts had decreasing trend1 • Boston rates 2009-11 decline from 42.6 to 39.9 (N of 12,000/year) • =>Evidence for change – but rates still at historically high levels 1 Wenjun Li, James Buszkiewicz, Robert Leibowitz, Anne Sheetz, Laura York, Thomas Land. Trends in overweight and obesity prevalence in Massachusetts school districts (2009-2013). Poster presented at New Balance Obesity Conference, Boston, MA 2013. 2 The Status of Childhood Weight in Massachusetts, 2011. Preliminary Results from Body Mass Index Screening in Massachusetts Public School Districts, 2009-2011. Massachusetts Department of Public Health. 2012.

13. CHOICES Pilot Study Modeling the Cost Effectiveness of Childhood Obesity Interventions in the United States

14. Why Cost Effectiveness? When you talk to decision makers about your work (what you can do to improve childhood obesity), they want to know three things • What is feasible (the intervention, program, policy)? • How effective is it? • What will it cost?

15. Cost-effectiveness Plane + Higher costs Better outcome Higher costs Worse outcome Difference in Cost - + Lower costs Worse outcome Lower costs Better outcome - Difference in Effectiveness

16. Why Cost Effectiveness? We cannot afford all the childhood obesity interventions we’d like to implement, so why not begin with those producing the “biggest bang for the buck?”

17. Pilot Cost-effectiveness Models • Originally funded by Robert Wood Johnson Foundation • Adapted Australian ACE (Assessing Cost Effectiveness) methodology • ACE Prevention and ACE Obesity • Continued work with JPB funding • CHOICES project (CHildhood ObesIty Cost Effectiveness Study)

18. CHOICES Team for Pilot • Harvard (Gortmaker, Cradock, Giles, Weinstein, Resch, Ward, Long, Barrett, Sonneville, Wright) • Columbia University (Wang) • Deakin (Swinburn, Carter, Moodie, Sacks) • Queensland (Vos, Barendregt)

19. Key Methods in CHOICES • Recruitment of a stakeholder group • Selection of interventions • Specification of the Intervention, implementation and costing • Intervention effects evidence synthesis • Modeling short and long term cost effectiveness • Uncertainty and sensitivity analyses • Implementation and equity considerations

20. Recruitment of Stakeholder Group • US policy makers and researchers • Nutrition/physical activity researchers • Programmatic experts • Provide advice on specification of interventions, data sources, implementation

21. Selection of Interventions • Selected by investigators, with stakeholder input • Both nutrition and physical activity interventions • Both policy and programmatic • Interventions can be clearly specified • Can be spread throughout US

22. The CHOICES Logic Model Intervention recruitment DALYS QALYS Health care costs averted Intervention Implementation BMI and Obesity

23. Intervention, Effects, and Costing Intervention recruitment DALYS QALYS Health care costs averted Intervention Implementation BMI and Obesity • Costs of • intervention • current practice Short term outcomes: $cost/BMI Long term Outcomes: health care offsets $cost/DALY

24. Intervention, Effects, and Costing Intervention recruitment DALYS QALYS Health care costs averted Intervention Implementation BMI and Obesity • Costs of • intervention • current practice Short term outcomes: $cost/BMI Long term Outcomes: health care offsets $cost/DALY

25. Intervention, Effects, and Costing Intervention recruitment DALYS QALYS Health care costs averted Intervention Implementation BMI and Obesity • Costs of • intervention • current practice Short term outcomes: $cost/BMI Long term Outcomes: health care offsets $cost/DALY

26. Intervention, Effects, and Costing Intervention recruitment DALYS QALYS Health care costs averted Intervention Implementation BMI and Obesity • Costs of • intervention • current practice Short term outcomes: $cost/BMI Long term Outcomes: health care offsets $cost/DALY

27. Implementation and Equity Considerations • Level of evidence (pathway to BMI) • Equity and impact on disparities • Acceptability to stakeholders • Feasibility • Sustainability • Side effects • Social and policy norms

28. Evidence from Pilot Interventions • Potential Impact of a Sugar-sweetened Beverage Excise Tax on BMI, Disability Adjusted Life Years, and Healthcare Costs in the United States (Long) • Cost-effectiveness of a state policy requiring minimum levels of moderate-to-vigorous physical activity during elementary school physical education classes (Barrett) • Potential Impact of Eliminating the Tax Subsidy of Food and Beverage Television Advertising Directed at Children and Adolescents on BMI, DALYs, and Healthcare Costs in the United States (Sonneville)

29. SSB Excise Tax Intervention • In 2012 8 states and 2 cities considered legislation to increase SSB taxes, although none passed1 • The modeled intervention consists of: An excise tax of one cent per ounce of SSB, applied nationally and administered at the state level 1 Yale Rudd Center SSB Excise Tax Map, 2012

30. Active PE Intervention Implementation of a state policy directing the U.S. state boards of education to include a requirement for 50% of PE time to be devoted to MVPA in the state PE curriculum for the elementary school level • Based on policies passed by state legislatures in Texas (SB 891, 2009) & Oklahoma (SB 1876, 2010) • Implemented within existing PE time provided • Children are exposed on ~2 days/week during the school year from the ages of 5-11 years

31. TV Advertising Intervention • Eliminate the tax deductibility of TV advertising costs for nutritionally poor foods and beverages advertised to children and adolescents ages 2-19

32. Conduct uncertainty and scenario analyses • Computer simulation model 2005 US population • Use @Risk and compiled programming model for uncertainty analyses: 10,000 iterations • Short-term Outcomes: Effects on BMI compared to natural history • Long-term Outcomes: BMI-mediated reductions in incidence of 9 diseases • Estimated disability-adjusted life years (DALYs) averted and healthcare cost savings • Discounted health effects and costs at 3.5%

33. Comparison of Results • All interventions show evidence for effectiveness • Widely varying: • Reach (population) • Total cost of intervention • Per person BMI change (those in the intervention) • Short Term Cost effectiveness ($cost/BMI)

34. Overview of Short Term Outcomes

35. Overview of Short Term Outcomes

36. Overview of Short Term Outcomes

37. Overview of Short Term Outcomes

38. Comparison to Clinical Interventions • High Five Intervention: $1000/BMI unit change1 • Bariatric Surgery: One estimate can be derived by assessing the average cost divided by average change in BMI.2-3 This indicates a cost of about $3000/BMI unit change 1 Wright, et al. Paper under review 2Kelleher DC, Merrill CT, Cottrell LT, Nadler EP, Burd RS. Recent national trends in the use of adolescent inpatient bariatric surgery: 2000 through 2009. JAMA Pediatr. 2013;167(2):126-132. 3Black JA, White B, Viner RM, Simmons RK. Bariatric surgery for obese children and adolescents: a systematic review and meta-analysis. Obes Rev. 2013.

39. Long-term Outcomes: SSB Excise Tax • Tax would be cost saving within 1 year of reaching full effect • Assuming effects would be maintained indefinitely:

40. Long Term Outcomes: Childhood Interventions • Long term cost-effectiveness and cost saving for childhood interventions require maintenance of effect for many years (30+) under current modeling assumptions

41. Additional Benefit: Revenue!

42. Health Equity: SSB Excise Tax • Concerns regarding potentially regressive nature of SSB excise tax have been raised • Empirical evidence on soda taxes demonstrates greater benefit for overweight children and children in African-American and low-income households1 • Substantial revenue can be earmarked for progressive nutrition and public health programs 1 Sturm et al. Health Affairs. 2010;29(5):1052-1058

43. Equity Considerations: PE Intervention • PE time requirements may not be as likely in schools with higher percentages of low income students • - Johnston et al. 2007; San Diego State University 2007 • So an Active PE policy may have a greater impact among higher income students who have more PE time, and be less likely to reach lower income students • Therefore, potentially inequitable in terms of socioeconomic status

44. Equity Considerations: TV Advertising • Because low income and ethnic minority children watch more TV, there is the potential to reduce obesity disparities and related health outcomes via this intervention

45. 40 CHOICES Cost Effectiveness Studies • Study Goals: • To generate cost effectiveness estimates for 40 of the most relevant childhood obesity interventions in the United States; • Using comparable methods • To engage policymakers and the general public in this issue, and provide guidance so that the most cost effective strategies for action are identified and become a focus of discussion and action.

46. Some New Environmental Change Strategies in Boston:Get Sugar Sweetened Beverages Out of Schools, Preschools, Afterschools, Government Worksites, Healthcare Institutions – and Assure Water Access

47. Reported Consumption of Servings (12 oz) per Day of Sugary Drinks, Boston High School Youth - Before and After Implementation of School Beverage Policy 1.68 1.40 Change in Boston P<0.001; no change in national sample Boston Youth Survey data were collected via a collaboration between the City of Boston and Harvard School of Public Health. N=1079 in 2004 and 1223 in 2006

48. PRC 2010-2014 core research project In partnership with Boston Public Schools, YMCA of Greater Boston, Boston Boys and Girls Clubs, Boston Centers for Youth and Families, Boston Public Health Commission Builds on PRC work with YMCA of the USA, BPS Food and Nutrition Services OSNAP Initiative

49. Goals for Nutrition and Physical Activity in Out-of-School Time • Include 30 minutes of moderate, fun, physical activity for every child every day • Offer 20 minutes of vigorous physical activity 3 times per week • Ban sugar-sweetened drinks from snacks served • Offer water as a drink at snack every day • Eliminate use of commercial broadcast TV/movies • Limit recreational computer time to less than one hour per day • Offer a fruit or vegetable option every day at snack • Ban foods with trans fats from snacks served • Ban sugar-sweetened drinks brought in from outside the snack program

50. Out of School Nutrition and Physical Activity Initiative Serving water during afterschool: Impact of Group Randomized Trial Catherine Giles, Erica Kenney, Steven Gortmaker, Rebekka Lee, Julie Thayer, Helen Mont-Ferguson, Angie Cradock